Motivations Counseling – Client Forms

Click on the icon below to print a form and bring the completed form with you to your therapy session, or

Click on the icon below to complete online and have the form automatically routed to your therapist:

New Clients:

Online Client Intake Forms (All Therapists)

Therapists: Susan Baker, Carolina Roman, Cathy Hein, Olivia Pudlo, and Belinda L.:

Individual Adult (18+) Forms
Child/Teen Forms
Couples Forms

Therapists: Ruba Afifi, Kelsey Engdorf, and Carissa Ferguson:

Individual Adult (18+)
Child/Teen Forms
Couples Forms

Additional forms to fill out if your therapist requests you to do so:
Adult Symptom Screener

Please review the following document covering our privacy practicies regarding your Protected Health Information (PHI) before completing the new client paperwork:
Notice of Privacy Practices Form

New or Existing Clients:

In-Person Informed Consent (for COVID-19)

Existing Clients:

If you need us to release your therapy/treatment information to a third party, please complete the following form authorizing us to do so:
Authorization to Release Information

For EMDR Therapy sessions, please complete the following informed consent form prior to the first treatment:
EMDR Informed Consent

If you need to change the credit card information we keep on file for you:
Credit Card On File

For clients needing Telehealth Counseling, please complete an informed consent form prior to the first treatment:
Telehealth Informed Consent - Individuals/Teens
Telehealth Informed Consent - Couples

Please print, fill out the required forms, and bring them with you to your next scheduled appointment
or, where applicable, complete the form online.